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CAMS-Affiliated Club Membership

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CAMS-Affiliated Club Membership National & International Licence Application/Renewal 2012 FiA Licence Levels: Circuit Licences (inc historic): PCC, CC, PC, NC, ICA, ICB, ICC, H1, H4 Off Road Licences: NOJ, NO, NON, NONJ, NOS Rally Licences: NRNJ, NRJ, CRN, CR, NRN, NR, IRN, IR Received Stamp Here Superkart Licences: PSKJ, PSK, NSKJ, NSK, ISK (office use only) CAMS Member Number: (ALL LICENCES ARE VALID FOR LEVEL 2 ACTIVITY) Type of licence(s) applied for: Your Fixed Expiry Date: Next Medical Due: Next Stress ECG Due: Personal Details (begin completing form here) Surname: Given names: Address: Town/Suburb: Post Code: Telephone: Work: ( ) Home: ( ) Mobile: Fax: ( ) Please attach Email: a passport size Email is used to inform CAMS members of news and updates and is not given to any third party. photo here Date of birth: / / 19 (if not previously supplied) Gender: Female Male Emergency contact (1): Name: Phone: ( ) Emergency contact (2): Name: Phone: ( ) Do you have Australian citizenship If ‘No’ nationality of passport, Yes No AND see Notes for Application – or permanent residency? Nationality. CAMS-Affiliated Club Membership Please list the CAMS-affiliated car club(s) of which you are a member (no abbreviations): Note: it is compulsory for all CAMS driver/navigator licence holders to be a member of a CAMS-affiliated car club. Full name of club (1): State: Full name of club (2): State: Now…continue to section 2 Office Use Only TYPE OF MEDICAL CAMS Member Number: International National Medical Expiry: / / Receipt No: Date: / / Amount: $ www.cams.com.au ©Confederation of Australian Motor Sport Ltd 2012 CAMS HOTLINE 1300 883 959 Page 1 Licence Selection Note Minimum Note Minimum Select Licences ages in brackets ages in brackets Tick the boxes next to the licence(s) you require Circuit Rally ICA International Circuit A (17) $ 1,650 IR International Rally (16) $ 423 ICB International Circuit B (17) $ 1,545 IRN International Rally Navigator (16) $ 423 ICC International Circuit C (17) $ 1,445 NR National Rally (16) $ 211 NC National Circuit (17) $ 428 NRN National Rally Navigator (16) $ 211 PC Provisional Circuit (16) $ 428 CR Clubman Rally (16) $ 150 CC Clubman Circuit (16) $ 263 CRN Clubman Rally Navigator (16) $ 150 PCC Provisional Clubman Circuit (16) $ 263 NRJ National Rally Junior (14) $ 46 NRNJ National Rally Junior Navigator (14) $ 46 Historic H1 International (17) $ 490 Off Road H4 International Regularity (17) $ 237 NOS National Off Road Stadium (16) $ 196 NO National Off Road (16) $ 196 Superkart NOJ National Off Road Junior (14) $ 46 ISK International Superkart (16) $ 743 NON National Off Road Navigator (16) $ 196 NSK National Superkart (16) $ 330 NONJ National Off Road Navigator Junior (12) $ 46 NSKJ National Superkart Junior (12) $ 125 PSK Provisional Superkart (16) $ 330 PSKJ Provisional Superkart Junior (12) $ 125 If you have selected more than one licence type please write the most expensive amount here $ OPTIONS AIMSS Levy: Australian Institute of Motor Sport Safety founded by CAMS is the driving force for the improvement of safety in $10 ü Motor Sport in Australia. To learn more please refer to: http://www.aimss.com.au (Levy not applicable to Junior Licences) Urgent Fee: Required if the licence is needed within 5 working days of application being received by CAMS. This does not $70 include the Australia Post delivery times. CAMS Manual: The complete CAMS manual is available online at www.camsmanual.com.au . If you would also like us to send you a printed copy, you may select this option. Grand Total: $ Payment I am paying by: Cash (ONLY if paying in person at your club or CAMS State Office) Cheque made payable to “Confederation of Australian Motor Sport Limited” Money Order made payable to “Confederation of Australian Motor Sport Limited” Credit Card – complete your details below: Visa MasterCard Card number: Expiry date: / Name on card: Cardholder signature: www.cams.com.au ©Confederation of Australian Motor Sport Ltd 2012 CAMS HOTLINE 1300 883 959 Page 2 New Licence Conditions PRE LICENCE LECTURE All new licence applicants are required to complete an online lecture on the requirements of the CAMS Manual of Motorsport and procedures involved in their particular discipline. N.B. If you have completed a valid Pre Licence Lecture in the last 24 months for the relevant discipline, you are not required to repeat this lecture. CAMS Customer Services will automatically enrol you in this course upon receipt of your application. Login details and guidelines will be sent to your nominated email account. I acknowledge that I am required to undertake an online lecture as a condition of receiving this licence. OBSERVED LICENCE TEST Are you : • Under the age of 25years? • Applying for a new licence in the following disciplines: Superkart; Off-Road Stadium? • Over the age of 25 years, applying for a Rally licence and not held a commercial road licence for over 5 years? • Applying for a Provisional Circuit or Provisional Clubman Circuit Licence and have NOT :- • competed in 5 CAMS Multi-Car Sprint (supersprint) or Regularity events within the last 24 months; OR • competed in 2 CAMS Tarmac Rally events within the last 24 months; OR • held a CAMS PCC/PC/PSK/NSK in the last four years. • Applying for a National Circuit or Clubman Circuit Licence and have NOT :- • held an AKA B-Grade licence (or higher) OR a CAMS NSK/ISKC licence; OR • previously held a CAMS NC (or higher) licence in the last 4 years. N.B. Evidence of competition history must be submitted with this application If you meet any of the previous criteria, you will need to complete an Observed Licence Test. An Observed Licence Test is where your driving style, ability and attitude are evaluated in simulated race conditions. Upon receipt of your application, CAMS will issue you with a Pre-Licence Authority (PLA) form which you will need to take with you along to your Observed Llicence Test. The cost and process varies from State to State. Please contact CAMS on 1300 883 959 for assistance in booking your Observed Licence Test. I acknowledge that I am required to complete an Observed Licence Test prior to receiving my licence. For further information regarding Observed Licence Tests, please refer to the Licence Section in the CAMS Manual of Motor Sport, which can be found online at www.camsmanual.com.au. Renewal Conditions For International A and B licences you must have been observed in one International event in the last 12 months. For International C Circuit Racing you need to have participated or been observed in one International event or two CAMS Events in the last 24 months. For Superkart Racing you need to have competed in at least one CAMS permitted event in the past 2 years. For International Rally you need to have participated in one International or two CAMS Rally events in the last 2 years. For Circuit, Rally and Off-Road Racing you need to have competed in at least in at least one CAMS permitted event in the past 4 years. Please contact CAMS if you have not met the above requirements. Please list the most recent CAMS or International event that you have participated in for each licence discipline. Discipline : Event : Date : Discipline : Event : Date : www.cams.com.au ©Confederation of Australian Motor Sport Ltd 2012 CAMS HOTLINE 1300 883 959 Page 3 Health Statement CAMS has made changes to the Medical Evaluation Process to ensure the safest possible driving conditions for all competitors, officials and spectators. Please complete the following section carefully and accurately. Medical History Do you have or have you ever had any significant or recurrent problems with the following? Diabetes Yes No Heart Disease / Chest Pain Yes No Epilepsy Yes No Fits / Fainting / Dizziness Yes No Anxiety / depression or other mental health condition Yes No Headaches / Migraine / Head Injury Yes No N.B. If you answered ‘Yes’ to any of the questions above then you must supply a report from your GP or Specialist Doctor. Further details about this requirement and a copy of the CAMS Medical Statement are available on the CAMS website. Other Conditions Do you suffer from any allergies? Yes No Do you wear glasses or contact lenses when driving? Yes No Do you suffer from Hearing Loss or Deafness? Yes No Is there any other relevant medical information that you wish to advise us of? Medical Assessment Requirements Are you : • Applying for a new or renewed International Licence? • Applying for a new Circuit, Historic, Superkart or Off-Road Stadium Licence? • Age 45 or over and applying for a new or renewed Circuit, Historic, Superkart or Off-Road Stadium Licence? If you ticked any of the above you must submit a Medical Report to CAMS filled in by your General Practitioner or Specialist. N.B. Applicants over 45 years of age are required to undergo a Medical Examination every second year only. www.cams.com.au ©Confederation of Australian Motor Sport Ltd 2012 CAMS HOTLINE 1300 883 959 Page 4 Declaration Statement to be read and completed by applicant: I agree to be bound by the rules and regulations of the event and the provisions of the National Competition Rules of the Confederation of Australian Motor Sport Limited (“CAMS”) and the International Sporting Code of the Federation Internationale d’Automobile (FIA). In exchange for being able to attend or participate in the event, I agree: • to release CAMS and Australian Motor Sports Commission Ltd, promoters, sponsor organisations, land owners and lessees, organisers of the event, their respective servants, officials, representatives and agents (collectively, the “Associated Entities”) from all liability for my death, personal injury (including burns), psychological trauma, loss or damage (including property damage) (“harm”) howsoever arising from my participation in or attendance at the event, except to the extent prohibited by law; • that CAMS and the Associated Entities do not make any warranty, implied or express, that the event services will be provided with due care and skill or that any materials provided in connection with the services will be fit for the purpose for which they are supplied; and • to attend or participate in the event at my own risk.
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